child & youth

Pediatric Telehealth Rounds

Creative Interventions for Mealtime Strategies

November 13, 2015

Carrie Owen, OT Chantal Lessard SLP

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Declaration of conflict

Speaker has nothing to disclose with regard to commercial support.

Speaker does not plan to discuss unlabeled/ investigational uses of commercial product.

Objectives 1. Identify the barriers to normal

feeding patterns in children.

2. Develop a practical mealtime plan based on identified mealtime strategies. 3. Gain an awareness of how a caregiver’s attention to the picky eater contributes to success. 4. Describe the referral process and CHEO’s feeding services

DSM-V Avoidant/Restrictive Food Intake Disorder Diagnostic Criteria 307.59 (F50.8) A. An eating or feeding disturbance (e.g. apparent lack of interest

in eating or food; avoidance based on the sensory characteristics of food; concern about the aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

Highlights of DSM-V Criteria

• Compared to DSM-IV criteria, expanded across the life span • Mutually exclusive with other eating and feeding disorders,

except pica. • Acknowledges sensitivities and conditioned negative responses • Family function may be affected, with heightened stress at

mealtimes • Encourages a multi-factorial understanding of feeding problems

FEEDING PROBLEMS ARE COMMON

• 25-30 % of typically developing kids • 80-90% of children with developmental disabilities • 50% of all toddlers have some variation of feeding

FEEDING PROBLEMS TYPICALLY SEEN INCLUDE:

• Those associated with a particular medical condition • Failure to thrive or poor weight gain • GERD (Gastroesophageal Reflux Disease) • Picky or finicky eaters • Texture progression issues • Cardiac, Cleft Lip and Palate

GERD SYMPTOMS IMPACTING FEEDING

• Regurgitation • FTT or poor weight gain • Sleep Feeds • Irritability with feeds, excessive crying • Recurrent pneumonias, cough, wheeze, stridor,

apnea • Sandifers syndrome (arching , torticollis) • Hiccups, sneezing, drooling

GERD Symptoms Continued

• Limited liquids intake • Difficulties in transitioning from purees to textures • Food refusal • Anemia

CONSTIPATION • Remember constipation as possible contributor

to feeding difficulties especially in kids with developmental delay!!

• It is not the frequency we are concerned about, more the discomfort and consistency

• Maximizing fluid and fibre intake is the first step • If still hard stools, consider medical management

Feeding

• Involves all organs, muscles and senses

First two years of life to learn

Oral-motor development

• 6 months: munching pattern • 6-8 months: tongue protrusion

when drinking • 7-12 months: rotary chew

begins to develop • 8 months: lateral movement of

the tongue

Oral motor development (cont.)

• 10 months: definite chewing movement

• 12 months: takes controlled bites of soft foods or readily dissolved crunchy foods

Coordination of chewing is fully mature by 3 to 6 years of age.

Development in Typical Child

• Liquid by nipple first 4-6 months • Strained smooth food by spoon (6

months) – sitting with minimal support

• Lumpy foods by 10-11 months – difficult if delayed until 14-16 months

• Cup drinking before 12 months (Arvedson 2009)

Critical Period for Solids (Illingworth & Lister, 1964)

• Spoon feeding by 6 months (developmental level) • Trunk support for sitting • Hand-to-mouth skills • No mixed textures per bite

When to refer:6mths on..

• -does not transition to purees or solids • - oral intake does not sustain good growth velocity • -significant limited food and textures accepted • -significant anxiety with eating

When to refer: 0-4 months

-coughing, gagging and excessive vomiting with breastfeeding or bottling

-appears physically uncomfortable and arching - takes longer than 40 minutes to drink

appropriate amount of formula or breast milk to sustain adequate growth -only feeds in their sleep

-inadequate caloric intake for growth

Mealtime Strategies

Functional Feeding

• Reasonable quantity of food

• Reasonable length of time

• Safe

• Pleasure

Table time

• Sitting for meals • At the table • Transition to meal

Structure Meal and Snack Time

• Schedule meals • Schedule snack • Limit drinking times

“Try It”

• Look • Sit by it • Touch • Bring to lips • Lick • On tongue • Swallow

Spitting

• Changing texture

• Changing taste • Trust

Meal Organization

• One preferred food • Small portions • Family/Daycare mealtime • Variety on everyone’s plate • Three foods ; preferred, less

preferred and new

• Limit mealtime length

• Self feeding

• Intake initially reduced

Practice

• Learning is messy

• Child learns through touch and play

• Thirty attempts

• Gagging

• Vomiting

• Cup drinking -slow it down with infant cereal, apple sauce or yogurt • Reflux “refusers”

• Natural Drinking Cup

Size of food pieces

Parental/Grandparent/Caregiver Attention Focus on the positive

What is it about McDonalds ???

Food chaining

• Start with liked foods • Change the food’s : Shape Colour Texture

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Pediatric Telehealth Rounds Join us next time: FASD Dr. Pilon & FASD Coalition of Ottawa November 20, 2015

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pedtelehealthrounds@cheo.on.ca